Prescription Drug Insurance: RAMQ Position Update

There, in black and white

NB Bulletin Vol. 15 N. 7, June 2012

The document entitled Info assurance médicaments and published on the website of the Régie de l’assurance maladie du Québec (RAMQ) presents the RAMQ’s positions on various topics related to Quebec’s Act respecting prescription drug insurance (hereinafter called “the Act”) and on the administration of private drug insurance plans. The RAMQ recently updated this document.

The update resolves several outstanding discussions between the Canadian Life and Health Insurance Association (CLHIA) and the RAMQ. For example, it clarifies which parties (spouse, children, groups of people, self-employed workers, etc.) must be covered by which type of plan (private or public). Normandin Beaudry published information bulletins on this subject in March, July and December of 2007.

Below is a summary of the key clarifications. Info assurance médicaments section numbers are indicated for each of the points discussed.

New interpretations

Section 1.1 The RAMQ changed its interpretation regarding eligible spouse coverage. Its previous interpretation was that individuals insured by a private plan must provide drug coverage for their spouse with whom they live. The notion of a shared household (“with whom they live”) has been removed in the RAMQ’s interpretation.

Section 1.6 The RAMQ now considers a person to have fulfilled his or her obligation to be insured if his or her private plan provides greater coverage than that offered by Quebec’s basic prescription drug insurance plan as regards the definition of spouse, child or person suffering from a functional impairment. This changes the RAMQ’s former interpretation that dictated that a private plan’s definition of dependents could not be broader than the definition prescribed by the Act and that people who do not meet this definition must be covered by the public plan. This clarification puts an end to the discussion between the CLHIA and the RAMQ as to which plan covers children between the ages of 18 and 21.

Section 2.1.1 The RAMQ clarifies that drug insurance coverage cannot be terminated based on age, either directly or indirectly. Therefore terminating coverage at age 65, for example, or using a formula based on a person’s age plus years of service, contravenes the Act. According to the RAMQ, however, use of a criterion based on a number of years following retirement would be acceptable.

Section 7.3 The RAMQ clarifies that, in the case of a child whose two parents do not reside at the same address, when the parent with whom the child lives is covered by the public plan, it is the other parent who must provide coverage for the child. If this other parent is eligible for membership in a private plan, he or she must enrol in this plan and cover the child as a dependent. However, if this other parent is not eligible for membership in a private plan but is covered as a dependent by his or her new spouse, he or she is not obligated to cover the child.

If both parents are covered by the public plan and the parent with whom the child lives becomes the spouse of an another individual covered by a private plan, this parent must be covered by his or her new spouse’s plan as soon as he or she meets the definition of spouse under the Act, and the coverage must extend to the child who lives with this parent.

Section 7.4 For private plans, the provision extending coverage to survivors, if applicable, is no longer limited to a maximum of 24 months.

Clarifications

Sections 3.2 and 3.3 The document now contains a section dealing with the RAMQ’s interpretation in relation to self-employed workers. Criteria are used to establish the definition of a self-employed worker. The RAMQ specifies that, unlike the employee/employer relationship, there is no relationship of subordination between the self-employed worker and his or her client, and that this relationship of subordination is what differentiates the employee from the self-employed worker. Examples are provided: an insurance representative working exclusively for one insurance company, a real estate agent working exclusively for one company and a salesperson working for a car dealership and paid on a commission basis are considered employees because the relationship is sufficiently subordinate. Business owners are considered self-employed workers. However, according to the RAMQ, if the company offers group insurance to its employees, owners and shareholders who work in the company have a relationship akin to an employee/employer relationship and must therefore enrol in the private plan established for their employees. Owners or shareholders who do not work in their companies cannot belong to the group.

Section 3.4 The RAMQ clarifies that, for associations in which membership is optional (e.g.: professional associations or orders), when these associations offer a private group plan, members under age 65 must enrol in this plan if it offers sick leave, accident or disability coverage, including prescription drug coverage. However, if these individuals qualify for coverage under another private plan, for example through their employer, spouse or professional order, they are free to choose among the private plans available to them.

Section 6.2 The RAMQ added a few clarifications regarding termination of coverage for disabled employees. It indicates that insurance coverage cannot be terminated in the event of disability leave. However, coverage can be terminated if the period of the absence results in the termination of the employment relationship and the disabled individual no longer meets the eligibility requirements. If the employment relationship terminates after a certain period of absence, the policy regarding the extension or termination of insurance coverage must be clearly outlined in the human resources management policies or the collective agreement.

Click here to access the document Info assurance médicaments (available only in French):